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Patients admitted to hospital can acquire multidrug-resistant organisms and Clostridium difficile from inadequately disinfected environmental surfaces. We determined the effect of three enhanced strategies for terminal room disinfection (disinfection of a room between occupying patients) on acquisition and infection due to meticillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, C difficile, and multidrug-resistant Acinetobacter. We did a pragmatic, cluster-randomised, crossover trial at nine hospitals in the southeastern USA. Rooms from which a patient with infection or colonisation with a target organism was discharged were terminally disinfected with one of four strategies: reference (quaternary ammonium disinfectant except for C difficile, for which bleach was used); UV (quaternary ammonium disinfectant and disinfecting ultraviolet [UV-C] light except for C difficile, for which bleach and UV-C were used); bleach; and bleach and UV-C. The next patient admitted to the targeted room was considered exposed. Every strategy was used at each hospital in four consecutive 7-month periods. We randomly assigned the sequence of strategies for each hospital (1:1:1:1). The primary outcomes were the incidence of infection or colonisation with all target organisms among exposed patients and the incidence of C difficile infection among exposed patients in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT01579370. 31 226 patients were exposed; 21 395 (69%) met all inclusion criteria, including 4916 in the reference group, 5178 in the UV group, 5438 in the bleach group, and 5863 in the bleach and UV group. 115 patients had the primary outcome during 22 426 exposure days in the reference group (51·3 per 10 000 exposure days). The incidence of target organisms among exposed patients was significantly lower after adding UV to standard cleaning strategies (n=76; 33·9 cases per 10 000 exposure days; relative risk [RR] 0·70, 95% CI 0·50–0·98; p=0·036). The primary outcome was not statistically lower with bleach (n=101; 41·6 cases per 10 000 exposure days; RR 0·85, 95% CI 0·69–1·04; p=0·116), or bleach and UV (n=131; 45·6 cases per 10 000 exposure days; RR 0·91, 95% CI 0·76–1·09; p=0·303) among exposed patients. Similarly, the incidence of C difficile infection among exposed patients was not changed after adding UV to cleaning with bleach (n=38 vs 36; 30·4 cases vs 31·6 cases per 10 000 exposure days; RR 1·0, 95% CI 0·57–1·75; p=0·997). A contaminated health-care environment is an important source for acquisition of pathogens; enhanced terminal room disinfection decreases this risk. US Centers for Disease Control and Prevention.

The COVID-19 pandemic is requesting highly effective protective personnel equipment, mainly for healthcare professionals. However, the current demand has exceeded the supply chain and, consequently, shortage of essential medical materials, such as surgical masks. Due to these alarming limitations, it is crucial to develop effective means of disinfection, reusing, and thereby applying antimicrobial shielding protection to the clinical supplies. Therefore, in this work, we developed a novel, economical, and straightforward approach to promote antimicrobial activity to surgical masks by impregnating silver nanoparticles (AgNPs). Our strategy consisted of fabricating a new alcohol disinfectant formulation combining special surfactants and AgNPs, which is demonstrated to be extensively effective against a broad number of microbial surrogates of SARS-CoV-2. The present nano-formula reported a superior microbial reduction of 99.999% against a wide number of microorganisms. Furthermore, the enveloped H5N1 virus was wholly inactivated after 15 min of disinfection. Far more attractive, the current method for reusing surgical masks did not show outcomes of detrimental amendments, suggesting that the protocol does not alter the filtration effectiveness. The nano-disinfectant provides a valuable strategy for effective decontamination, reuse, and even antimicrobial promotion to surgical masks for frontline clinical personnel.

Antimicrobials have enabled medical advancements over several decades. However, the continuous emergence of resistance to antimicrobials restricts our ability to treat diseases and curbs efforts to achieve universal health coverage and the health-related sustainable development goal. Antimicrobial resistance is a neglected global crisis that requires urgent attention and action.1Appropriate prescription and optimized use of antimicrobials guide the principles of antimicrobial stewardship activities, together with quality diagnosis and treatment, and reduction and prevention of infections.2 During the current coronavirus disease 2019 (COVID-19) pandemic there are potential threats that could affect antimicrobial stewardship activities and drive antimicrobial resistance. For instance, many individuals presenting with mild disease without pneumonia or moderate disease with pneumonia receive antibiotics.3 A review of studies published on hospitalized COVID-19 patients identified that while 72% (1450/2010) of patients received antibiotics, only 8% (62/806) demonstrated superimposed bacterial or fungal co-infections.4 WHO also reports that azithromycin is being widely used with hydroxychloroquine although it is not yet recommended outside of COVID-19 clinical trials.Furthermore, hospital admissions increase the risk of health-care-associated infections and the transmission of multidrug-resistant organisms, which in turn lead to increased antimicrobial use.5 A recent study conducted in intensive care units in 88 countries showed that although only 54% (8135/15 165) of patients had suspected or proven bacterial infection, 70% (10 640/15 165) of them had received at least one antibiotic either for prophylaxis or treatment purposes.

The hospital environment is a source of pathogen transmission. The effect of enhanced disinfection strategies on the hospital-wide incidence of infection has not been investigated in a multicentre, randomised controlled trial. We aimed to assess the effectiveness of four disinfection strategies on hospital-wide incidence of multidrug-resistant organisms and Clostridium difficile in the Benefits of Enhanced Terminal Room (BETR) Disinfection study. We did a prespecified secondary analysis of the results from the BETR Disinfection study, a pragmatic, multicentre, crossover cluster-randomised trial that assessed four different strategies for terminal room disinfection in nine hospitals in the southeastern USA. Rooms from which a patient with a specific infection or colonisation (due to the target organisms C difficile, meticillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci (VRE), or multidrug-resistant Acinetobacter spp) was discharged were terminally disinfected with one of four strategies: standard disinfection (quaternary ammonium disinfectant, except for C difficile, for which 10% hypochlorite [bleach] was used; reference); standard disinfection and disinfecting ultraviolet light (UV-C), except for C difficile, for which bleach and UV-C was used (UV strategy); 10% hypochlorite (bleach strategy); and bleach and UV-C (bleach and UV strategy). We randomly assigned the sequence of strategies for each hospital (1:1:1:1), and each strategy was used for 7 months, including a 1-month wash-in period and 6 months of data collection. The prespecified secondary outcomes were hospital-wide, hospital-acquired incidence of all target organisms (calculated as number of patients with hospital-acquired infection with a target organism per 10 000 patient days), and hospital-wide, hospital-acquired incidence of each target organism separately. BETR Disinfection is registered with ClinicalTrials.gov, number NCT01579370. Between April, 2012, and July, 2014, there were 271 740 unique patients with 375 918 admissions. 314 610 admissions met all inclusion criteria (n=73 071 in the reference study period, n=81 621 in the UV study period, n=78 760 in the bleach study period, and n=81 158 in the bleach and UV study period). 2681 incidenct cases of hospital-acquired infection or colonisation occurred during the study. There was no significant difference in the hospital-wide risk of target organism acquisition between standard disinfection and the three enhanced terminal disinfection strategies for all target multidrug-resistant organisms (UV study period relative risk [RR] 0·89, 95% CI 0·79–1·00; p=0·052; bleach study period 0·92, 0·79–1·08; p=0·32; bleach and UV study period 0·99, 0·89–1·11; p=0·89). The decrease in risk in the UV study period was driven by decreases in risk of acquisition of C difficile (RR 0·89, 95% CI 0·80–0·99; p=0·031) and VRE (0·56, 0·31–0·996; p=0·048). Enhanced terminal room disinfection with UV in a targeted subset of high-risk rooms led to a decrease in hospital-wide incidence of C difficile and VRE. Enhanced disinfection overcomes limitations of standard disinfection strategies and is a potential strategy to reduce the risk of acquisition of multidrug-resistant organisms and C difficile. US Centers for Disease Control and Prevention.

Although research has shown that the COVID-19 disease is most likely caused by airborne transmission of the SARS-CoV-2 virus, disinfection of potentially contaminated surfaces is also recommended to limit the spread of the disease. Use of electrostatic sprayers (ESS) and foggers to rapidly apply disinfectants over large areas or to complex surfaces has emerged with the COVID-19 pandemic. ESSs are designed to impart an electrostatic charge to the spray droplets with the goal of increasing deposition of the droplets onto surfaces, thereby promoting more efficient use of the disinfectant. The purpose of this research was to evaluate several spray parameters for different types of sprayers and foggers, as they relate to the application of disinfectants. Some of the parameters evaluated included the spray droplet size distribution, the electrostatic charge, the ability of the spray to wrap around objects, and the loss of disinfectant chemical active ingredient due to the spray process. The results show that most of the devices evaluated for droplet size distribution had an average volume median diameter ≥ 40 microns, and that four out of the six ESS tested for charge/mass produced sprays of at least 0.1 mC/kg. A minimal wrap-around effect of the spray deposition onto a cylindrical object was observed. The loss of disinfectant active ingredient to the air due to spraying was minimal for the two disinfectants tested, and concurrently, the active ingredient concentrations of the liquid disinfectants sprayed and collected 3 feet (1 meter) away from the spray nozzle do not decrease.

The only biocidal iodine species in topical iodine disinfectants is molecular iodine (I2). I2, a biomolecule, has broad-spectrum antimicrobial activity and does not generate resistance. Physicians, regulatory agencies, and scientists have assumed that I2 is responsible for the skin staining and irritation associated with the clinical use of iodine disinfectants; this assumption is deeply embedded in the medical community but is not supported with empirical data. This study provides the first experimental data that measure the biocompatibility of I2 with human skin. Human skin explants in tissue culture were evaluated at 3, 7, and 24 h after being exposed to I2 (500 to 15,000 ppm). Cell viability was measured relative to phosphate-buffered saline using 3-[4,5-dimethylthiazol-2yl]-2,5-diphenyl-tetrazolium bromide (MTT). The biocidal activity of I2 vapor emitted from silicone was demonstrated against bacteria growing on agar to confirm I2 off-gassing from skin was an active biocide. Additionally, statistically significant bacterial reductions with both gas and solution phase I2 were observed in a static and dynamic five-species wound biofilm. The data suggest that high, e.g., 50–5000 ppm, levels of I2 should be incorporated into topical iodine disinfectants instead of the very low (0.2–10 ppm) levels found in 10% povidone iodine products currently in use.

Bacteraemia is an important cause of morbidity and mortality in critically ill children. Our objective was to assess whether daily bathing in chlorhexidine gluconate (CHG) compared with standard bathing practices would reduce bacteraemia in critically ill children. In an unmasked, cluster-randomised, two-period crossover trial, ten paediatric intensive-care units at five hospitals in the USA were randomly assigned a daily bathing routine for admitted patients older than 2 months, either standard bathing practices or using a cloth impregnated with 2% CHG, for a 6-month period. Units switched to the alternative bathing method for a second 6-month period. 6482 admissions were screened for eligibility. The primary outcome was an episode of bacteraemia. We did intention-to-treat (ITT) and per-protocol (PP) analyses. This study is registered with ClinicalTrials.gov (identifier NCT00549393). 1521 admitted patients were excluded because their length of stay was less than 2 days, and 14 refused to participate. 4947 admissions were eligible for analysis. In the ITT population, a non-significant reduction in incidence of bacteraemia was noted with CHG bathing (3·52 per 1000 days, 95% CI 2·64–4·61) compared with standard practices (4·93 per 1000 days, 3·91–6·15; adjusted incidence rate ratio [aIRR] 0·71, 95% CI 0·42–1·20). In the PP population, incidence of bacteraemia was lower in patients receiving CHG bathing (3·28 per 1000 days, 2·27–4·58) compared with standard practices (4·93 per 1000 days, 3·91–6·15; aIRR 0·64, 0·42–0·98). No serious study-related adverse events were recorded, and the incidence of CHG-associated skin reactions was 1·2 per 1000 days (95% CI 0·60–2·02). Critically ill children receiving daily CHG bathing had a lower incidence of bacteraemia compared with those receiving a standard bathing routine. Furthermore, the treatment was well tolerated. Sage Products, US National Institutes of Health.

Blood cultures are indispensable for detecting life-threatening bacteremia. Little is known about associations between contamination rates and topical disinfectants for blood collection in adults. We sought to determine whether a change in topical disinfectants was associated with the rates of contaminated blood cultures in the emergency department of a single institution. This single-center, retrospective observational study of consecutive patients aged 20 years or older was conducted in the emergency department (ED) of a university hospital in Japan between August 1, 2018 and September 30, 2020. Pairs of blood samples were collected for aerobic and anaerobic culture from the patients in the ED. Physicians selected topical disinfectants according to their personal preference before September 1, 2019; alcohol/chlorhexidine gluconate (ACHX) was mandatory thereafter, unless the patient was allergic to alcohol. Regression discontinuity analysis was used to detect the effect of the mandatory usage of ACHX on rates of contaminated blood cultures. We collected 2141 blood culture samples from 1097 patients and found 164 (7.7%) potentially contaminated blood cultures. Among these, 445 (20.8%) were true bacteremia and 1532 (71.6%) were true negatives. Puncture site disinfection was performed with ACHX for 1345 (62.8%) cases and with povidone-iodine (PVI) for 767 (35.8%) cases. The regression discontinuity analysis showed that mandatory ACHX usage was significantly associated with lower rates of contaminated blood cultures by 9.6% (95% confidence interval (CI): 5.0%–14.2%, P  < 0.001). Rates of contaminated blood cultures were significantly lower when ACHX was used as the topical disinfectant.

The importance of disinfection has recently increased owing to the spread of infections, such as coronavirus disease 2019 (COVID-19). However, exposure to the biocidal products used for disinfection poses health risks. This study aimed to determine the safe use of biocides and the potential for secondary exposure in the general population. To obtain information on the exposure factors on site, an interview survey was conducted for 2 weeks and 10 days using a questionnaire. Toxicology studies were performed to determine the toxicity of each chemical in various biocidal products. The inhalation and dermal exposure algorithms in ConsExpo 4.0, a software developed by the Dutch National Institute for Public Health and the Environment (RIVM), were used to assess the risk of active substances in biocidal products. The average amounts of disinfectants and pesticides used in indoor environments per unit time were 5948.50 ± 72,434.76 mg and 201.61 ± 305.91 mg, respectively. Ethanol had the highest inhalation hazard quotient (HQ inh ) of 1.48E+02 while sodium dichloroisocyanurate had the lowest value of 1.74E−10. The HQ inh /HQ der ratios for the 10 active substances ranged from 1.51E+00 to 2.73E+05 were greater than 1, indicating that inhalation exposure had a greater effect than dermal exposure. The hazard index (HI) of the 10 active substances, excluding ethanol, was less than 1, indicating the absence of potential health risks. Therefore, to reduce the health risks associated with secondary exposure, disinfection should be performed during periods when individuals are away from the site to be disinfected, such as after regular working hours, and individuals should be encouraged to enter this site the following day instead of after the disinfection exercise. Methods, such as applying an active substance from a biocidal product to a cloth or fabric to carry out the disinfection protocol, should also be considered.

In this study, a chlorine dioxide solution (UC-1) composed of chlorine dioxide was produced using an electrolytic method and subsequently purified using a membrane. UC-1 was determined to contain 2000 ppm of gaseous chlorine dioxide in water. The efficacy and safety of UC-1 were evaluated. The antimicrobial activity was more than 98.2% reduction when UC-1 concentrations were 5 and 20 ppm for bacteria and fungi, respectively. The half maximal inhibitory concentrations (IC50) of H1N1, influenza virus B/TW/71718/04, and EV71 were 84.65 ± 0.64, 95.91 ± 11.61, and 46.39 ± 1.97 ppm, respectively. A 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) test revealed that the cell viability of mouse lung fibroblast L929 cells was 93.7% at a 200 ppm UC-1 concentration that is over that anticipated in routine use. Moreover, 50 ppm UC-1 showed no significant symptoms in a rabbit ocular irritation test. In an inhalation toxicity test, treatment with 20 ppm UC-1 for 24 h showed no abnormality and no mortality in clinical symptoms and normal functioning of the lung and other organs. A ClO2 concentration of up to 40 ppm in drinking water did not show any toxicity in a subchronic oral toxicity test. Herein, UC-1 showed favorable disinfection activity and a higher safety profile tendency than in previous reports.